Healthcare Reimbursement in Saint Helena, Ascension and Tristan da Cunha: Who Pays What Depending on Your Situation

CLEISS cites neither Saint Helena, nor Ascension, nor Tristan da Cunha in the list of social security agreements in force with France or in its list of foreign schemes, and its page on the British scheme mentions no overseas territory. For a temporary stay, they fall under “other countries or situations not covered”: on site, no cover is possible unless an agreement applies. There is therefore no European card, no aggregation of periods and no cross-cover. Locally, care is charged for: Jamestown hospital applies a resident rate and a visitor scale, Ascension offers care to employees under contract, and Tristan da Cunha asks for insurance including evacuation to Cape Town. Four parties are involved depending on status: the maintained French scheme (secondment), the CFE, international health insurance and the local public system.

The notions of reimbursement basis and out-of-pocket cost help you compare plans. The organisation of care is presented in the guide healthcare system in Saint Helena, Ascension and Tristan da Cunha.

A local-contract employee comes under the local scheme and is no longer covered by French social security, CLEISS reminds us. On Saint Helena, a care policy provides that people in full-time employment who live on the island permanently receive care on the same terms as residents, including referrals to South Africa; people on fixed-term contracts who do not live there permanently pay for local care at the standard rate, and treatment abroad is not provided unless paid for by the employer or the employee. Government employees, and holders of a long-term entry permit or of a work permit from a private employer for more than 183 days, come under the resident rate according to the published scale. On Ascension, all medical and dental care is free for employees under contract and their accompanying family. See the glossary entry on the local contract.

A seconded employee remains a member of the French scheme during the assignment, for three years renewable once according to CLEISS. Their contributions are paid in France, but they may also have to pay those of the host country. They are covered up to what they would have received in France: they send their fund the paid invoices with form S 3125c, and top-up health insurance is advised if care is expensive. See seconded or expatriate and the seconded employee glossary.

A self-employed person on Saint Helena has a work permit and a long-term entry permit; the published scale attaches holders of a long-term permit or of a work permit of more than 183 days to the resident rate, and the individual situation should be confirmed in writing with the Health Directorate. CLEISS indicates that a self-employed expatriate can join the CFE voluntarily for sickness and maternity; international insurance completes the arrangement for medical evacuation. See digital nomad insurance.

A student has no European card. Before age 30, the CFE offers a youth plan whose price is calculated on quotation; student insurance with evacuation remains the usual option. See student insurance abroad.

Spouse and children: the Saint Helena scale extends the resident rate to spouses, partners and dependants of certain categories of residents (people born, registered, naturalised or adopted on the island); for the family of a foreign employee, the immigration policy provides that access to care at local rates continues as long as a family member carries on an activity, with proof of insurance or means for the family’s evacuation. On Ascension, those accompanying an employee under an “accompanied” contract receive free care. The CFE and international insurers both offer family contracts. See expat family insurance.

A retiree does not come under form S1, which is valid in Europe. CLEISS indicates that it is up to them to check with local institutions how far the local scheme covers their care, and that they may join the CFE voluntarily or take out private insurance. The CFE retirees’ plan is for holders of a pension from a French basic scheme, with no health questionnaire; it covers only care received abroad, while care in France remains covered by the French compulsory scheme. On Saint Helena, the immigration policy provides that permit holders who are neither in employment, nor in business, nor investors are not entitled to care at local rates, hence the importance of insurance. See the guide retiree health insurance abroad and the page retirement in Saint Helena, Ascension and Tristan da Cunha.

During a temporary stay in France, cover applies to holders of a French pension with at least 15 years of insurance in France; an accompanying spouse is not covered, and a hospital stay of more than one month requires prior recognition. A retiree who is no longer a tax resident in France pays neither CSG nor CRDS, according to CLEISS.

The CFE is a voluntary social protection body. In France, it reimburses according to the principles of Assurance Maladie (the French national health insurance); abroad, reimbursement depends on the country where care is delivered and the type of treatment, with a reimbursement basis applied as a rate or flat amount on the actual expense. The scale specific to the territory can be read in the CFE table of cover: the difference from the price charged remains the member’s responsibility. The guide CFE reimbursement details this mechanism.

• Plans: main plan, youth plan (under 30) and retirees’ plan; the final price depends on the country, age and family composition, and is obtained on quotation.
• Waiting period: cover starts immediately if membership takes place before departure or within three months of settling abroad; beyond that, the waiting period is three months before age 44 and six months from age 45.
• Maternity: conception must follow membership or attachment as a dependant.

On return to France, service-public indicates that a CFE member may keep their expatriate benefits for three months under conditions. Without the CFE, anyone who does not start work immediately must show three consecutive months of residence in France before filing their application for Universal Health Protection (form S1106); anyone who resumes employment is covered from the first hour worked. See reducing the waiting period and the page returning to France.

International health insurance at the first euro reimburses actual costs within the limits of its contract, after any deductible, waiting periods and exclusions. It answers the structure of care on these islands: a small public service, charged-for care, and evacuations that run to thousands of pounds sterling. Contracts are compared on the annual ceiling, the coverage zone, evacuation and the handling of pre-existing conditions; the minimum amounts required on entry (£175,000 on Saint Helena, £500,000 of air evacuation on Ascension) serve as a benchmark.

A tourist has no on-site cover from Assurance Maladie. CLEISS recommends taking out travel insurance suited to the real cost of care in the country, or checking an existing cover such as that of a bank card. On Saint Helena, a visitor holding a short-term entry permit comes under the visitor scale and must hold valid insurance or sufficient means to cover their medical costs. Reimbursement on return to France of unforeseen care is a possibility and not an obligation, and medical repatriation is not covered by health insurance. See long-stay travel insurance.

The Saint Helena Health Directorate scales are published by level of care, in pounds sterling; amounts change with government revisions and can be consulted on its website. Insurer ceilings are those of the chosen contract. The benchmarks below reproduce the structure of the visitor scale and the information published by the three governments.

• Consultation: the visitor scale distinguishes nurse triage and an assessment by a general practitioner with tests, each charged per procedure, as well as a surcharge outside office hours; an out-of-hours consultation is charged at a higher rate to visitors than to residents. A seconded employee submits their paid invoices to their fund.
• Hospitalisation: the visitor scale includes admission fees and a daily rate depending on the level of care (general ward, single room, intensive care), running from hundreds to several thousand pounds a day, to which are added surgical procedures classified by level. It is prudent to check the insurer’s guarantee before a planned admission.
• Medical evacuation: the scale provides flat rates for evacuation by boat (with a nurse or doctor on board) of several thousand pounds, and billing at actual cost for air evacuation; this is the reason for the insurance required on entry.
• Medicines: prescriptions are charged per item or at cost price plus an administration fee for visitors; the reimbursement rate depends on the insurer’s contract.
• Dental: the visitor scale covers only dental emergencies, with no routine or cosmetic care. Residents have the hospital dental service, which does not place implants. On Ascension, dental care is free under contract. Dental ceilings are read in the terms of each contract (CFE or international insurance).
• Optical: no information on optical cover is published on the pages consulted; international insurance or the CFE should be compared on this point.
• Maternity: Jamestown hospital has a maternity unit and midwives; the visitor scale includes a delivery fee and a postnatal fee, plus hospital days. On Ascension, a midwife works at the hospital; on Tristan da Cunha, pregnant women travel to Cape Town to give birth, according to the hospital page. For the CFE, conception must follow membership.

The reimbursement guide and the page expat health insurance give benchmarks; Expavy helps you set these options against your situation.